Gastroesophageal Reflux (GER and GERD) in Infants and Children

John Mersch, MD, FAAP

Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.

David Perlstein, MD, MBA, FAAP

Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

What are GER and GERD in infants and children?

Gastroesophogeal reflux (GER) is the upward flow of stomach contents from the
stomach into the esophagus ("swallowing tube"). While not required by its
definition, these contents may continue from the esophagus into the pharynx
(throat) and may be expelled from the mouth. GER differs from vomiting
in that it is generally not associated with a violent ejection. Moreover, GER is
generally a singular event in time whereas the vomiting process is commonly
several back-to-back events that may ultimately completely empty all stomach
contents and yet still persist ("dry heaves"). The difference
between GER and GERD (gastroesophogeal reflux disease) is a matter of severity
and associated consequences to the patient.

The large majority of healthy, full term infants will have episodes of
"spitting up" or "wet burps," which technically qualify to be considered GER.
These infants generally do not seem in distress before, during, or after by the
reflux process. Likewise, the loss of calories as an outcome of GER is
inconsequential since growth parameters including weight gain are not affected.
Lastly, there seem to be no short or long term consequences of these reflux
experiences. In short, infants with GER are "messy spitters."

The very name of GERD ("disease") implies a much different condition.
Infants and children with GERD often experience distress as a consequence of
their reflux even if the refluxed stomach contents are not completely ejected
from the mouth. Infants and young children may loose so many calories by
expulsion that growth is compromised. Some infants or children with GERD
may even become averse to feeding due to repeated associations with feeding and
pain. Finally, there are a number of short and long term consequences of
GERD that are not associated with infants and children with GER. These
will be discussed further in this article.

What causes GER and GERD in infants and children?

Infants with GER are a reflection of their immature nervous system. In
most infants the junction between the esophagus and stomach is "closed," opening
only to allow passage of formula or
breast milk into the stomach or to allow the
escape of swallowed air via burping.

During episodes of reflux, this junction is continuously open allowing a
backwards flow of stomach contents into the esophagus. This reverse flow
may occur as a consequence of a relatively large volume of fluid relative to a
smaller stomach volume, pressure on the abdominal cavity (for example, placed
face down [prone]
following a feeding), or overfeeding. Infant GER occurs in over 50% of
healthy infants with a peak incidence (65%) at approximately 4 months of age.
Most episodes resolve by 12 months of age.

GERD also reflects an opening of the esophageal-stomach junction similar to
infant GER. The reasons for GERD, however, are not considered to reflect
an immature nervous system. Factors that may contribute to GERD in infants and
children include:

Increased pressure on the abdomen (over
eating,
obesity, straining with stool due to
constipation,
etc.).

Slower than normal emptying of stomach contents may predispose
infants or children to GERD.

Certain medications, foods, and beverages may also be implicated in
facilitating such pathological reflux.

Recent studies indicate that
between 2% to 8 % of children 3 to 17 years of age experience GERD symptoms
(detailed later).